Should We Worry about Non-Ischemic Lesions?

In the last decade, the interest in atheroma plaque morphology and its role in clinical events has been on the rise. Several studies have shown the use of IVUS to sort out plaque into lipidic rich (LRP) and thin cap fibroatheromas (TCFA). These morphologies have been associated with major cardiovascular events at followup.   

At present, the more frequent use of OCT with its high resolution has allowed to accurately differentiate TCFA from thick cap fibroatheroma (ThCFA) and non-lipid rich plaque (non-LRP).  

The study looked at patients from the prospective multicenter trial COMBINE FFR-OCT, which combined functional assessment with FFR and morphological assessment with OCT to evaluate non-ischemic lesions in diabetic patients. 

The purpose was to study the impact of different atheroma plaque (TCFA, ThCFA, non-LRP) on the risk of developing adverse events at followup. 

Primary end point was a composite of cardiovascular death, target vessel related MI, target vessel revascularization and hospitalization for unstable angina within 18 months. 

Of 550 patients included in the study, 390 had patients with diabetes and ≥1 lesion with FFR >0.80 underwent OCT evaluation. Mean age was 67, and 63% were men. Mean FFR value was 0.88. The ThCFA group presented a higher percentage of patients on statins vs. the other two groups. 

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There were no differences in primary end point between LRP and non-LRP patients. 

Looking at LRP patients, TCFA plaque presented higher events rate vs ThCFA (13.3% vs 3.8%; HR, 3.8 [95% CI, 1.5–9.5] P<0.01). This difference in favor of TCFA was also observed when comparing against non-LRP patients. On the contrary, there were no differences between ThCFA and non-LRP patients when it came to adverse events at follow up. 

Conclusion

Among diabetic patients with non-ischemic lesions, lipidic rich lesions and TCFA are associated with higher events rate in the future. OCT assessment showed one third of patients presented TCFA; these might benefit of a more aggressive medical treatment. We need more studies to assess the different therapeutic strategies. 

Dr. Andrés Rodríguez.
Member of the Editorial Board of SOLACI.org.

Original Title: Thin-Cap Fibroatheroma Rather Than Any Lipid Plaques Increases the Risk of Cardiovascular Events in Diabetic Patients: Insights From the COMBINE OCT–FFR Trial.

Reference: Enrico Fabris MD et al Circ Cardiovasc Interv. 2022;15:e011728.

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